Closing the Loop in Sonoma County: Part I

This is the first of a 3-part series highlighting a collaborative of organizations in Sonoma County that use Purple Binder’s Referral Network to connect patients to vital social supports when they most need it. The collaborative includes West County Health Centers, Petaluma Health Center, St. Joseph Hospital, Petaluma People Services Center, and Food for Thought.

Bridging the Gap Between Healthcare and Housing

Sonoma County’s healthcare and housing organizations provide critical supports for the county’s homeless population, but it can be difficult for them to coordinate care.

As more research demonstrates housing’s impact on health, providers in Sonoma County are strengthening partnerships to better provide care for the homeless and housing insecure.

West County Health Centers (WCHC), a federally qualified health center located in West Sonoma County, is using Purple Binder to help establish primary care for homeless ER patients, and to communicate more effectively with social service providers and housing and shelter operators located on the other side of the County, in Santa Rosa.

Connecting Homeless Patients to Primary Care

Helping West Sonoma County’s homeless residents establish primary care is a key priority for WCHC. According to Jed Heibel, manager of the Health Care for the Homeless Program at WCHC, there’s a nationwide push for FQHCs and hospitals to work together to identify emergency room high utilizers, many of whom have unstable housing.

“The idea is that FQHCs and hospitals [should] talk on a regular basis about who is using the ER most frequently and how we can get regular care for them once they’re discharged,” he says. “In the homeless population, the moment when someone is being discharged from the hospital is usually the point at which he or she is ready make a change in his or her life.”

Heibel stresses, however, that in order to get these patients into follow-up care, it’s important to reach them immediately upon discharge, which is difficult to do with the traditional referral system.

Typically, hospital social workers call in referrals to health centers like WCHC. Problems arise when no one is able to respond to calls until the patient has already left the hospital.

With Purple Binder, hospital social workers can make patient referrals without ever having to pick up a phone.

“Social workers everywhere are overwhelmed,” says Heibel. In his experience, if social workers in a hospital emergency room can’t reach someone after several calls, they’re likely to discharge patients without any way to guarantee that they make it to follow-up care.

Using Purple Binder’s Referral Network, primary care providers and hospital social workers are able to coordinate care for members of the homeless population at a critical moment.

“The homeless population is a notoriously difficult population to track. If ER providers can go into Purple Binder and make a referral to us before a patient is discharged, we can expedite the process of getting that patient into primary care,” Heibel says.

This issue, a national problem, is particularly acute in West Sonoma County, where much of the homeless population lives in encampments in wooded areas.

“When someone goes back to a camp we may not see them for 2-3 weeks,” Heibel says.

“With Purple Binder, we can know when [a homeless patient] who’s been in the hospital is expected in town in 2-3 hours, which is a huge advantage for us.”

Healthcare and Housing in Sonoma County

The Health Care for the Homeless program, Heibel explains, funds health centers to provide care that’s specifically designed to serve the homeless.

“An exciting part of this program is the expanded scope of services available at the FQHC. We now have an opportunity to better support the shelters by offering the highly specialized multidisciplinary care teams necessary to help shelter participants stabilize their lives and succeed with their housing goals,” Heibel says. “We are saying ‘Let’s integrate systems of care for greater impact.’ Purple Binder allows for this integrated care, even when operating from different facilities.”

It’s the most efficient and immediate care coordination network system that I’ve seen -Jed Heibel, Manager, Healthcare for the Homeless, West County Health Centers

The program requires strong coordination between the health center and local shelter operators. Any disconnect or breakdown in communication is a real problem. However, communication between West County Health Centers and housing providers can be difficult due to geography.

“In Sonoma County, our two main shelter facilities and most social and government services are located in what we call the 101 corridor, in the city of Santa Rosa,” he says. “West County Health Center is about 22 miles west of Santa Rosa, but it feels a lot further.”

Heibel sees the Referral Network as an opportunity to strengthen coordination between healthcare and housing in Sonoma County, helping to overcome the geographic barriers of the service landscape.

Confronting a National Challenge

Sonoma County is far from the only area where the healthcare and housing sectors lack coordination. In fact, it’s a national issue.

““There is a lot of emphasis on breaking down these silos, but the collaborative work to do that is complicated,” Heibel says. “A large part of the challenge is overcoming the limitations related to the way the two sectors store data.”

Homelessness service providers are required by government to use what’s called the HMIS system, Heibel explains. Healthcare providers, on the other hand, use electronic health records to store data about patients.

“No one is really sharing data,” Heibel says. “There’s no clear path of not just referring, but tracking what’s done when a patient referral is made between those two silos of healthcare and housing.”

This is where Heibel sees a role for Purple Binder’s Referral Network– to bridge the data gap between these two systems.

“Purple Binder is one platform where with a fairly limited amount of patient data, you can fast-track people to the appropriate services,” Heibel says.